Relationship Between Quantitative Tumor Consistency and Pathological Factors in Intracranial Meningioma.

BACKGROUND: The consistency of intracranial meningiomas is an important clinical factor because it affects the success of surgical resection. This study aimed at identifying and quantitatively measuring pathological factors that contribute to the consistency of meningiomas. Furthermore, we investigated the relationship between these factors and preoperative neuroradiological imaging. METHODS: We analyzed 42 intracranial meningioma specimens, which had been removed at our institution between October 2012 and March 2018. Consistency was measured quantitatively after resection using an industrial stiffness meter. For pathological evaluation, we quantitatively measured the collagen-fiber content through binarization of images of Azan-Mallory-stained section. We assessed calcification and necrosis semi-quantitatively using images acquired of Hematoxylin and Eosin stained samples. The relationship between collagen-fiber content rate and imaging findings was examined. RESULTS: The content of collagen fibers significantly positively correlated with meningioma consistency (p < 0.0001). Collagen-fiber content was significantly higher in low- and iso-intensity regions compared with high-intensity regions on the magnetic resonance T2-weighted images (p = 0.0148 and p = 0.0394, respectively). Calcification and necrosis showed no correlation with tumor consistency. CONCLUSIONS: The quantitative hardness of intracranial meningiomas positively correlated with collagen-fiber content; thus, the amount of collagen fibers may be a factor that determines the hardness of intracranial meningiomas. Our results demonstrate that T2-weighted images reflect the collagen-fiber content and are useful for estimating tumor consistency preoperatively and non-invasively.

Transient Ischemic Attack: Which Determines Diffusion-Weighted Image Positivity?

AIM OF THE STUDY: Diffusion-weighted image (DWI) of magnetic resonance imaging (MRI) can reveal high signal lesion in up to 50% of transient ischemic attack (TIA) patients. However, it is not well-known which factors determine developing DWI positivity. In order to answer this question, we analyzed factors relevant to DWI positivity in TIA patients. METHODS: We had 257 stroke patients at a university emergency/neurology wards. They were 140 men, 117 women, mean age 72 (45-88) years. Among them, 24 (9.3%) had TIA (14 men, 10 women, mean age 71 [58-82] years). All patients underwent a 1.5T MRI. In 24 TIA patients, we investigated the following parameters in relation with stroke maturation: ABCD2 score, smoking habits, blood profile, HbA1C, dyslipidemia, coagulation factors, carotid echography, electrocardiography, cardiac echography, chest X-ray, neurological symptom/signs, imaging, and recurrence of neurological symptom on follow-up. RESULTS: In 24 TIA patients, 13 (54%) were DWI positive and 11 (46%) were DWI negative. After an extensive analysis, all parameters were not relevant to DWI positivity except for plasma osmolarity, i.e., plasma osmolarity in DWI positive cases (305.3 mOsm/l) is significantly higher than that in DWI negative cases (301.3 mOsm/l) (P = .0064). As for recurrence, 4 of 24 TIA patients recurred. They were 1 (9.0%) of 11 DWI negative cases and 3 (23.1%) of 13 DWI positive cases. Therefore, DWI positive cases recurred more frequently than DWI negative cases did, although it did not reach statistical significance. CONCLUSIONS: TIA with DWI positivity in our institute was 54%, closely associated with initial dehydration and might predict stroke recurrence.

Levels of circulating soluble LR11, a regulator of smooth muscle cell migration, are highly associated with atherosclerotic plaques in patients with carotid artery stenosis.

BACKGROUND: The levels of plasma sLR11, released from intimal SMCs, are positively associated with intima-media thickness (IMT) in asymptomatic subjects. We have evaluated the yet unknown pathological significance of sLR11 for plaque conditions in patients with carotid artery stenosis. METHODS: The presence of LR11 in carotid plaques was investigated using autopsy specimens. A clinical ultrasonography study for elucidating relationships between sLR11 and plaque condition was performed in 46 patients. RESULTS: Immunohistochemistry showed high levels of LR11 in SMCs within thickened intima and at the media-intima border of atherosclerotic carotid plaques. The levels of sLR11 in patients were clearly elevated compared to healthy controls. Univariate analysis of sLR11 revealed significant positive correlation with plaque score and a tendency to correlate with the stenotic fraction. Univariate and multiple regression analyses of plaque scores showed that sLR11, maximum IMT, and HDL-cholesterol independently determined plaque score. Finally, univariate analysis of initial sLR11 levels for changes in imaging markers after one-year follow-up showed that initial sLR11 levels significantly correlated with stenotic fraction progression. CONCLUSIONS: The levels of sLR11, abundantly expressed in carotid atherosclerotic plaques, are highly associated with increased plaque score. sLR11 levels may be predictive of plaque conditions in patients with advanced carotid atherosclerosis.

Bladder recovery relates with increased mid-cingulate perfusion after shunt surgery in idiopathic normal-pressure hydrocephalus: a single-photon emission tomography study.

AIMS OF STUDY: It is reported that severe bladder disorder in idiopathic normal-pressure hydrocephalus (iNPH) is predicted by right frontal hypoperfusion. However, it is not known whether bladder recovery is predicted by brain perfusion change after shunt surgery. To address this issue, we compared bladder and brain function before and after shunt surgery in iNPH. METHODS: We enrolled 75 patients in the study. Before and 12 months after shunt surgery, we analyzed brain perfusion by SPECT and bladder disorder by a specialized grading scale. The scale consisted of grade 0, none; grade 1, urinary urgency and frequency; grade 2, urinary incontinence 1-3 times a week; grade 3, urinary incontinence >daily; and grade 4, loss of bladder control. More than one grade improvement is defined as improvement, and more than one grade decrement as worsening; otherwise no changes. RESULTS: Comparing before and after surgery, in the bladder-no-change group (32 cases) there was an increase in blood flow which is regarded as reversal of enlargement in the Sylvian fissure and lateral ventricles (served as control). In contrast, in the bladder-improved group (32 cases) there was an increase in bilateral mid-cingulate, parietal, and left frontal blood flow (p < 0.05). In the bladder-worsened group (11 cases) no significant blood flow change was observed. CONCLUSION: The present study showed that after shunt surgery, bladder recovery is related with mid-cingulate perfusion increase in patients with iNPH. The underlying mechanism might be functional restoration of the mid-cingulate that normally inhibits the micturition reflex.

[Infected subdural hematoma having a surgery of chronic subdural hematoma 1 year ago:a case report].

We report a case of an infected subdural hematoma that occurred 1 year after burr-hole irrigation for chronic subdural hematoma. A 78-year-old woman who had developed left hemiparesis was admitted to our hospital. A computed tomography(CT)scan revealed the presence of a chronic subdural hematoma in the right hemisphere. Her clinical symptoms improved immediately after emergency burr-hole irrigation, which allowed her discharge from the hospital. One year after the initial surgery, she developed an infection of the urinary tract infection, which led to severe pyelonephritis and septic shock. Treatment of the urological symptoms eliminated the systemic inflammation. One month after the urinary infection, the patient was readmitted to the hospital in a comatose state. A CT scan showed regrowth of a residual subdural hematoma surrounded by a thick capsule, causing a midline shift in the brain. An emergency operation for removal of the subdural hematoma by burr-hole irrigation was performed, and pus was drained from the subdural mass. Microbiological cultures of the abscess revealed the presence of Proteus mirabilis. After surgery, the patient was administered an antibiotic treatment for three weeks and she was discharged with no neurological deficits. Cultures of blood from the septic shock as well as from the abscess both revealed the presence of Proteus mirabilis. Therefore, a diagnosis of infected subdural hematoma, which was caused by hematogenous infection, was made. We conclude that attention should be paid to the risk of infection of the hematoma capsule in subdural hematomas.

"Invisible" brain stem infarction at the first day.

BACKGROUND: In specific stroke cases, serial diffusion-weighted magnetic resonance imaging (DW MRI) on day 1 was unable to show a lesion, whereas that on day 4 and later clearly revealed a lesion. However, clinical features of this phenomenon ("invisible" brain stem infarction [IBI] at the first day) have not been fully delineated. METHODS: We retrospectively recruited 212 stroke patients in the Emergency Unit and Neurology Department. Among these, we studied patients with IBI. Definition of IBI is that acute and clear brain stem symptoms/signs on arrival were ameliorated at discharge and appearance of high signal intensity on serial DW images with low apparent diffusion coefficient (ADC) by 1.5 T MRI with 2-mm slices. RESULTS: IBI were found in only 6 patients. Day 1 invisible stroke was found only in the brain stem (17%, 6 of 35) but none (0 of 177) in the hemispheric infarction (P < .05). In most patients with IBI, DW MRI turned out visible at the third/fourth day. Before the fourth day, DW/ADC signal changes in patients with IBI were minimal. In IBI, lesion size (mean 2.7 mm(2)) was smaller than that of visible cases (mean 7.3 mm(2)). In IBI, lesion location was mostly at the dorsolateral medulla. In IBI, sensory disturbance was significantly more common (67%) than visible cases (24%; P < .05), whereas dysarthria was less common (0%; P < .01) than visible cases (66%; P < .01). CONCLUSIONS: It is likely that patients with smaller stroke volume, sensory disturbance, and medullary location are prone to develop IBI. When evaluating stroke using MRI criteria, recognition of IBI is important to start early management.

Bladder function of patients with Parkinson's disease.

Bladder function of patients with Parkinson's disease alters significantly: the majority of patients have overactive bladder (urinary urgency/frequency) with little or no post-void residuals. This seems to be the result of an altered brain-bladder relationship, as in Parkinson's disease, the frontal-basal ganglia D1 dopaminergic circuit that normally suppresses the micturition reflex is altered. The pathophysiology of the bladder dysfunction in Parkinson's disease differs from that in multiple system atrophy; therefore, it might also aid in differential diagnosis. The effects of levodopa, the major drug to treat motor dysfunction, on the bladder in Parkinson's disease vary significantly; therefore, add-on therapy is often required. Anticholinergic drugs are the first-line treatment, with particular care for cognitive function in elderly patients. The second-line treatment includes serotonergics drug, desmopressin and others. Newer modalities include deep brain stimulation that improves the bladder in Parkinson's disease; and botulinum toxin is promising, particularly in difficult cases. These treatments might be beneficial in maximizing the patients' quality of life.

Ruptured aneurysm of the PICA communicating artery: a case report.

A 47-year-old man presented with a rare aneurysm arising from the posterior inferior cerebellar artery communicating artery (PICA com A), manifesting as subarachnoid with intraventricular hemorrhage. Cerebral angiography showed a defect of the left PICA, and the left PICA region was supplied by a communicating artery formed by the fusion of branches from the right PICA and right vertebral artery. Aneurysms arose in the communicating artery, and a small, unruptured fusiform aneurysm was observed adjacent to a ruptured aneurysm. Trapping was performed for the 2 aneurysms with occipital artery (OA)-PICA bypass. Six cases of aneurysms occurring in this vessel including ours have been reported, and hemodynamic factors and congenital fragility of the arterial wall have been suggested as causative factors. Ours is the first case in which a ruptured aneurysm of this vessel was treated surgically with concurrent vascular reconstruction. If the aneurysm has a shape that is difficult to clip, the affected vessel is difficult to preserve, and collateral blood flow to the affected PICA region is considered insufficient, trapping with OA-PICA bypass is recommended.

Weak detrusor contractility correlates with motor disorders in Parkinson's disease.

Limited attention has been paid to the relationship between urinary symptoms or urodynamic findings and motor disorders in Parkinson's disease (PD). We aimed to correlate pressure-flow urodynamic parameters with video-gait analysis parameters in PD. We recruited 41 patients with PD (25 men and 16 women; age, 70.6 ± 8.5 years; H & Y motor grading: 2 [range, 1-3]; disease duration: 4 years [range, 1-7]; taking levodopa 300 mg/day [range, 100-400]). All patients underwent pressure-flow urodynamics (parameters: first sensation, bladder capacity, detrusor overactivity [noted in 24 patients], and Watts factor [WF]) and video-gait analysis (parameters: time and number of strides for 5-m gait [simple task] and time for timed up and go [complex task]). Statistical analysis was made by Mann-Whitney's U-test for analyzing the relation between detrusor overactivity and gait as well as Spearman's rank-correlation coefficient test for analyzing the relation between the remaining parameters and gait. We found no relation between filling-phase urodynamics (detrusor overactivity, first sensation, and bladder capacity) and video-gait analysis parameters. By contrast, we found a significant relation between voiding-phase urodynamics (WF, reflecting detrusor power) and all three video-gait analysis parameters (reflecting lower-half bradykinesia and loss of postural reflex) in our PD patients (P < 0.01). The close relation between the WF and motor disorders in the present study suggests that, though clinically mild, a weak detrusor in PD might have a central origin. We should follow postvoid residual volume carefully in PD patients with advanced gait disorder, because postvoid residual volume might increase in such patients.

The study of systemic general circulation disturbance during the initiation of therapeutic hypothermia: Pit fall of hypothermia.

AIMS: Neurointensive care has reduced the mortality and improved the outcome of patients for severe brain damage, over recent decades, and made it possible to perform this therapy in safety. However, we have to understand the complications of this therapy well. The purpose of our study was to determine the systemic circulation disturbance during the initiation of therapeutic hypothermia by using this continuous neurointensive monitoring system. MATERIALS AND METHODS: Ten severe brain damage patients treated with hypothermia were enrolled. All patients had Glasgow Coma Scale (GCS) less than or equal to 8, on admission. RESULTS: We verified that heart rate, cardiac output, and oxygen delivery index (DO2I) decreased with decreasing core temperature. We recognized that depressed cardiac index (CI) was attributed to bradycardia, dehydration, and increased systemic vascular resistance index (SVRI) upon initiation of hypothermia. CONCLUSION: Although the hypothermia has a therapeutic role in severe brain damage patients, we have to carry out this therapy while maintaining their cardiac output using multimodality monitoring devices during hypothermia period.

Effects of edaravone on a rat model of punch-drunk syndrome.

Punch-drunk syndrome (PDS) refers to a pathological condition in which higher brain dysfunction occurs in a delayed fashion in boxers who have suffered repeated blows to the head. However, the underlying mechanisms remain unknown. This study attempted to elucidate the mechanism of higher brain dysfunction observed following skull vibration in two experiments involving a rat model of PDS. Experiment 1 evaluated the effects of edaravone on histological changes in the rat brain tissue after skull vibration (frequency 20 Hz, amplitude 4 mm, duration 60 minutes). The amount of free radicals formed in response to skull vibration was very small, and edaravone administration reduced the number of glial fibrillary acidic protein and advanced glycation end product-positive cells. Experiment 2 examined the time course of change in learning ability following skull vibration in Tokai High Avoider rats. The learning ability of individual rats was evaluated by the Sidman-type electric shock avoidance test 5 days after the last session of skull vibration or final anesthesia and once a month for 9 consecutive months. Delayed learning disability was not observed in rats administered edaravone immediately after skull vibration. These results suggest that free radical-induced astrocyte activation and subsequent glial scar formation contribute to the occurrence of delayed learning disabilities. Edaravone administration after skull vibration suppressed glial scar formation, thereby inhibiting the occurrence of delayed learning disabilities.

Thalamic infarction disrupts spinothalamocortical projection to the mid-cingulate cortex and supplementary motor area.

Thalamic infarction presenting with heat anesthesia is rare. A 62-year-old man developed acute heat anesthesia and deep sensory disturbance in the right half of his body, but sensation for cold and pain was preserved. The resolution of these symptoms was accompanied by the gradual development of central dysesthesia. Magnetic resonance imaging (MRI) and computed tomography (CT) findings showed a small infarction in the left thalamic principal somatosensory nucleus (ventral caudal) and pulvinar. Single-photon emission CT showed hypoperfusion in the mid-cingulate cortex (mid-CC) and supplementary motor area (SMA), however, the primary and secondary somatosensory cortices were spared. Somatosensory-evoked potential findings were normal. The disruption of spinothalamocortical projection to the mid-CC and SMA is attributable to the development of central dysesthesia in the present case.

Isolated Hemiataxia and Cerebellar Diaschisis after a Small Dorsolateral Medullary Infarct.

Isolated hemiataxia after a medullary infarct is rare. We describe a case of isolated hemiataxia after a small infarct localized at the ipsilateral dorsolateral medulla. An 83-year-old man developed acute onset of ataxia in the left arm and in both legs. Speech and extraocular movement were normal, and he did not have any other neurological manifestations. Brain MRI showed a small infarct localized at the left dorsolateral medulla, which involved the inferior cerebellar peduncle. (123)ECD-SPECT showed hypoperfusion in the left cerebellar hemisphere without clear vascular territory. Neuroimaging findings for our patient suggested the involvement of the inferior cerebellar peduncle that projects to the cerebellum in our patient.

[A rare massive parenchymal metastasis in central nervous system from abdominal non-Hodgkin lymphoma: effectiveness of stereotactic radiosurgey: case report].

A 62-year-old female presented with a rare massive parenchymatous metastasis from abdominal malignant lymphoma. Computed tomography and magnetic resonance image revealed a large enhanced mass in the right basal ganglia. 123I-IMP SPECT showed increased uptake on both early and delayed images. A stereotactic biopsy was performed; histological examination revealed a diffuse large B-cell malignant lymphoma. The patient underwent stereotactic radiosurgery (SRS). Short-term cliniconeuroradiological follow-up showed both neurologic improvement and virtually complete disappearance of the tumor. Our findings suggest that 123I-IMP SPECT can help differentiate malignant lymphoma from benign lesions and other malignant brain tumors. In addition, SRS with conventional radiotherapy may be an effective therapeutic strategy to control malignant lymphoma.